Sec. 38a-522. Medicare supplement policies. Coverage of home health aide service.
Sec. 38a-522. Medicare supplement policies. Coverage of home health aide
service. (a) As used in this section, "Medicare" means the Health Insurance for the Aged
Act, Title XVIII of the Social Security Amendments of 1965, as amended (Title I, Part
I of P.L. 89-97); "Medicare supplement policy" means any group health insurance policy
or certificate delivered or issued for delivery to any resident of the state who is eligible
for Medicare, except any long-term care policy as defined in section 38a-528.
(b) No insurance company, fraternal benefit society, hospital service corporation,
medical service corporation or health care center may deliver or issue for delivery any
Medicare supplement policy which has an anticipated loss ratio of less than seventy per
cent for any group Medicare supplement policy except that a minimum anticipated loss
ratio of seventy-five per cent shall be required for any group Medicare supplement policy
defined in Section 1882(g) of Title XVIII of the Social Security Act, 42 USC 1395ss(g),
as amended. No such company, society, corporation or center may deliver or issue for
delivery any Medicare supplement policy without providing, at the time of solicitation
or application for the purchase or sale of such coverage, full and fair disclosure of any
coverage supplementing or duplicating Medicare benefits.
(c) Each Medicare supplement policy shall provide coverage for home health aide
services for each individual covered under the policy when such services are not paid
for by Medicare, provided (1) such services are provided by a certified home health aide
employed by a home health care agency licensed pursuant to sections 19a-490 to 19a-503, inclusive, and (2) the individual's physician has certified, in writing, that such
services are medically necessary. The policy shall not be required to provide benefits
in excess of five hundred dollars per year for such services. No deductible or coinsurance
provisions may be applicable to such benefits. If two or more Medicare supplement
policies are issued to the same individual by the same insurer, such coverage for home
health aide services shall be included in only one such policy. Notwithstanding the
provisions of subsection (g) of this section, the provisions of this subsection shall apply
with respect to any Medicare supplement policy delivered, issued for delivery, continued
or renewed in this state on or after October 1, 1986.
(d) Whenever a Medicare supplement policy provides coverage for the cost of prescription drugs prescribed after the hospitalization of the insured, outpatient surgical
procedures performed on the insured in any licensed hospital shall constitute "hospitalization" for purposes of such prescription drug coverage in such policy.
(e) Notwithstanding the provisions of subsection (g) of this section, each Medicare
supplement policy delivered, issued for delivery, continued or renewed in this state on
or after October 1, 1988, shall provide benefits, to any woman covered under the policy,
for mammographic examinations every year, or more frequently if recommended by
the woman's physician, when such examinations are not paid for by Medicare.
(f) The Insurance Commissioner shall adopt such regulations as he deems necessary
in accordance with chapter 54 to carry out the purposes of this section.
(g) The provisions of this section shall apply with respect to any Medicare supplement policy delivered, issued for delivery, continued or renewed in this state on or after
October 1, 1987, and prior to the effective date of any regulations adopted pursuant to
section 38a-495a.
(P.A. 90-243, S. 106; P.A. 92-60, S. 25; 92-111, S. 3, 4.)
History: P.A. 92-60 in Subsec. (a) made technical corrections for statutory consistency; P.A. 92-111 amended Subsec.
(g) to make the provisions of this section applicable to Medicare supplement policy regulations adopted pursuant to Sec.
38a-495a.
See Secs. 38a-495 and 38a-495a re Medicare supplement policies and certificates.